Failure to Provide Ordered Nutritional Supplements and Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to provide physician-ordered nutritional supplements as prescribed for two residents and did not notify the physician of significant weight changes for two residents. For one resident with multiple diagnoses including depression, anxiety, intellectual disabilities, cerebral palsy, and encephalopathy, there was a documented 10-pound weight loss over one month. Physician orders required a house supplement after meals, but the Medication Administration Record (MAR) showed multiple instances where the supplement was not administered due to unavailability. Progress notes confirmed the supplement was not available on several dates, and there was no documentation that the physician was notified of these missed doses. Another resident experienced a significant weight loss of over 10% in one month, but the clinical record did not show that the physician was notified of this change. The DON stated that the dietitian emails weight loss notifications to nursing leadership, but there was a misunderstanding about who was responsible for notifying the physician, resulting in a lack of physician notification. A third resident, at risk for malnutrition and with dysphagia, also had a significant weight loss and a physician order for a daily house supplement. The MAR indicated several days when the supplement was not available, and again, there was no documentation of physician notification regarding the missed supplement or the significant weight loss. Observations during the survey confirmed that the ordered supplements were not consistently available in medication carts, nourishment pantries, or central supply. Staff interviews corroborated that the supplement was sometimes unavailable and that the physician should have been notified when supplements could not be administered or when significant weight changes occurred. Facility policy required both the administration of supplements as ordered and physician notification of significant weight changes, but these procedures were not followed.